VIDEO Line-assisted complete closure of large gastric mucosal defects by use of multiple clip-and-line technique Figure A, EGD view showing a slightly depressed 12-mm lesion at the fornix of the stomach B, A 40-mm gastric mucosal defect after ESD C, Attachment of the first clip-and-line to normal mucosa on the proximal side of the mucosal defect D, After gathering of both sides of the defect, attachment of additional clips to close the defect E, Complete closure of the large gastric mucosal defect, taking about 20 minutes in all F, Attachment of most clips to the area of the defect month after ESD G, EGD view showing a 20-mm submucosal tumor at the fornix of the stomach H, Large intraoperative perforation I, Complete closure of the large perforation by line-assisted complete closure by use of multiple clip-and-line technique, taking about 18 minutes in all ESD, endoscopic submucosal dissection Perforation is a serious adverse event of endoscopic resection Although they are usually managed by endoscopic clip closure, 3% to 6% of perforations during gastric endoscopic resection cannot be completely closed and therefore require emergency surgery We developed the line-assisted complete closure (LACC) technique to close large colorectal mucosal defects after endoscopic submucosal dissection (ESD) and have applied this technique to large mucosal defects after gastric ESD A 40-mm mucosal defect resulting from gastric ESD was closed by LACC using a multiple clipand-line technique (Figs 1A and B; Video 1, available online at www.VideoGIE.org) Briefly, a nylon line was tied to a clip (HX-610-090; Olympus, Tokyo, Japan) mounted onto an applicator (HX-110LR; Olympus) The clip was retracted into the applicator and inserted Written transcript of the video audio is available online at www.VideoGIE.org www.VideoGIE.org Volume 1, No : 2016 VIDEOGIE 49 Video into the accessory channel The first clip-and-line was attached to the normal mucosa on the proximal side of the defect (Fig 1C) A second clip without a line was inserted into the accessory channel and anchored to the distal side of the defect, and the clips were gathered by pulling the line Additional clips were attached to keep the closure secure and tight (Fig 1D) Because of its large size, however, the entire defect could not be completely closed by the first clip-and-line After the line tied to the first clip was cut with scissor forceps (FS-3L-1; Olympus), a second clip-and-line was attached in the same way, resulting in complete closure of the large gastric mucosal defect (Fig 1E) Most clips were attached to the area of the defect month after ESD, and the mucosal defect was completely repaired (Fig 1F) We were able to close a large intraoperative perforation by using the same technique A 20-mm GI stromal tumor located at the fornix of the stomach was treated by ESD (Fig 1G) During ESD, a large perforation occurred (Fig 1H) First, the muscular layer defect was closed by clips After that, the mucosal layer was completely closed 50 VIDEOGIE Volume 1, No : 2016 by LACC (Fig 1I) Recently, simple closure techniques such as loop clip or slipknot closure have been reported; however, we consider LACC to be a simpler and more effective technique because it achieves a tight closure by pulling the line during the procedure DISCLOSURE All authors disclosed no financial relationships relevant to this publication Yasushi Yamasaki, MD, Yoji Takeuchi, MD, Minoru Kato, MD, Noriya Uedo, MD, Ryu Ishihara, MD, Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan Copyright ª 2016 The Authors Published by Elsevier, Inc on behalf of the American Society for Gastrointestinal Endoscopy This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/) http://dx.doi.org/10.1016/j.vgie.2016.08.008 www.VideoGIE.org ... to the distal side of the defect, and the clips were gathered by pulling the line Additional clips were attached to keep the closure secure and tight (Fig 1D) Because of its large size, however,... way, resulting in complete closure of the large gastric mucosal defect (Fig 1E) Most clips were attached to the area of the defect month after ESD, and the mucosal defect was completely repaired... entire defect could not be completely closed by the first clip- and -line After the line tied to the first clip was cut with scissor forceps (FS-3L-1; Olympus), a second clip- and -line was attached in the